Maternal Health of Female Sex Workers in Six Low- and Middle-Income Countries

Purpose: The purpose of this study was to examine factors that impact maternal health, including antenatal care and skilled birth attendance, work behavior, and substance use during pregnancy among female sex workers (FSW) across six low- and middle-income countries (LMIC). The added knowledge may inform programs, policies, and funding on a level equivalent to those for HIV prevention to reduce the high numbers of maternal deaths among this population. Methods: This was an exploratory mixed methods study. Quantitative data were gathered from cross-sectional surveys completed by 1352 FSW. The proxy respondent methodology was used to identify behaviors and characteristics related to maternal health in pregnancy among FSW. Descriptive statistics were used to summarize quantitative survey responses, and text analytics to summarize answers to open-ended questions. Results: An estimated 86.1% of FSW were reported to be mothers, but access to antenatal care (ANC) was reported to be only 28.7%. Barriers to ANC included cost, stigma, and accessibility. In some countries the majority of FSW were reported to give birth in brothels. Nearly a quarter (24.4%) of FSW were reported to work until the onset of labor, with most (75.9%) returning to work less than a month postpartum. Consumption of alcohol and other substances during pregnancy was reportedly very high (79.0% and 65.1% respectively), and 70.6% of FSW were reported to experience depression during the postpartum period. Participants expressed the need for respectful FSW-sensitized prenatal, intrapartum, and postpartum care at a location where they felt comfortable. Conclusion: This exploratory study revealed multiple risk factors experienced by pregnant FSW that may contribute to high numbers of maternal deaths reported among FSW, including poor access to affordable, quality maternal healthcare, and lack of service programs to address social determinants of health. Plain Language Summary: This study looked at pregnancy-related healthcare among female sex workers (FSW) in six low- and middle-income countries (LMIC). It explored factors that could affect the risk of complications during pregnancy and delivery, such as prenatal appointment attendance, delivering with a skilled provider, substance use in pregnancy, maternal depression, and physically demanding work through late gestation. Using a structured questionnaire, we asked FSW participants about these practices among their peers. There was some variation between countries, but overall we found that FSW tended to have low attendance at prenatal appointments, often had babies in places without skilled medical care, reported high rates of drug and alcohol use during pregnancy, and often worked until the late in pregnancy and returned to work shortly after the baby was born. The FSW expressed a need for quality and affordable pregnancy-related services where the care is respectful and sensitized to the unique needs and pressures of FSW mothers. Keywords: female sex workers, maternal health, sex work, public health, global perspectives, service needs, antenatal care access